Finding treatment for opiate addiction fraught with challenges

When opiate addiction reaches a crisis point, either through a medical emergency or a drug user's life falling apart, it can be hard knowing where to turn.

Matthew Colonna III, a licensed independent clinical social worker and director of hospital-based psychiatric emergency services with Riverside Community Care in Milford, coordinates acute evaluations and referrals for patients who come into the emergency department at Milford Regional Medical Center with signs of addiction.

Some come by ambulance after an overdose. Others might report significant pain that doesn't respond to normal doses of medication, because they've built up a tolerance.

"One common theme I see across patients with prescription opiate problems is their really strong belief that this isn't a problem: 'I'm not addicted to this. My doctor's prescribing them,''' Mr. Colonna said.

"You have to point out to them that, 'Yeah, you're taking it for a medical problem but you've lost your spouse, your job, your home.' You go through all of the impact the medications have had. They're a harder nut to crack to get them even into treatment."

What's more, he said, "The patient's biggest fear is what treatment is like: 'I don't want to be in a program with people with addiction problems.' In their minds, there's a huge difference."

Mr. Colonna said that emergency room doctors sometimes show the patient his or her profile of controlled substance prescriptions reported to the state Department of Public Health's Prescription Monitoring Program database. "That's often effective shock treatment, to show them how much they're using. It has been helpful and we have caught patients in doctor shopping," he said.

But when the staff makes calls to find detox or treatment, "What we find are there are no beds available anywhere in the state," he said.

"The patient is left with sitting in the ER or go home and trying to call from the community. That's unfortunately our default for detox," he said.

That delay often results in a relapse.

"In substance abuse admissions, you've got to strike while the iron is hot," he said.

Sometimes, people get an addicted family member into detox by having him or her committed by the court under Section 35 to a stay in a treatment center; or more likely, because beds aren't available in treatment centers, to Bridgewater State Hospital for men or Framingham state prison for women. It's often a last-ditch attempt for help.

"It's criminalizing substance abuse and putting family members at the forefront of forcing treatment," Mr. Colonna said.

Plus, court-ordered treatment is just not that effective.

"Typically, they say they spent the first week or two upset that they were there. They do not engage with treatment," he continued. "You want their natural motivation for treatment to build up to the point that they're ready to change. I don't think people make change when the gun is held at their head."

Mr. Colonna said the most effective substance abuse referrals are those to intensive outpatient programs, when the patient doesn't need detox.

Robin A. Nagle, a licensed clinical social worker, addiction counselor and clinical supervisor at Spectrum Health Systems in Worcester, said the quickest way to get someone into Spectrum's outpatient program, which offers counseling, groups and methadone treatment, is through same-day admissions.

Early on Monday and Thursday mornings, people seeking treatment come in on a first-come, first-served basis and see intake staff, meet with a clinician and see a doctor for an assessment and history. If they're appropriate for the treatment, they'll often receive methadone the first day.

"It's an arduous day, but it gets them into treatment right away," Ms. Nagle said.

She said people come to the program typically through self-referral, but sometimes are referred by a doctor or agency. Many have been in treatment before but need the methadone, which blocks the effects of opiates, to get them off the illicit drugs for a period of time.

"A lot of people are afraid of overdosing and it's a tough situation," Ms. Nagle said. "They might have come in with an opiate prescription that they originally got from a doctor for a medical issue, it could have been a chronic medical condition, and there's been a progression.

"Sometimes people don't have an idea how strong it can be or how dangerous it can be. It seems sometimes they're not very educated, or had Vicodin because they had their wisdom teeth out and they were, Wow, using Vicodin more than they thought they'd ever be."

Heroin use is also common because it's so inexpensive, she said.

Perhaps the most challenging part of recovery, Ms. Nagle said, is recognizing how much effort it takes to be successful.

"Sometimes I think people come in in denial: 'Just take care of the medical part and I'll be fine,''' she said. "Building a support system, finding resources in the community, starting to be honest. I think those are important."

She said Spectrum is developing a family forum for friends or family to meet once a month to learn about addiction and recovery. "I think if the family is on board, that makes a huge difference," she said. "And sometimes families don't understand. I'm sure sometimes they're afraid or angry. So we're all about, I think, trying to build a bridge."